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Background: Clinician educators are experts in procedural skills that students need to learn. Some clinician educators are interested in creating their own procedural videos but are typically not experts in video production, and there is limited information on this topic in the clinical education literature. Therefore, we present a tutorial for clinician educators to develop a procedural video., Objective: We describe the steps needed to develop a medical procedural video from the perspective of a clinician educator new to creating videos, informed by best practices as evidenced by the literature. We also produce a checklist of elements that ensure a quality video. Finally, we identify the barriers and facilitators to making such a video., Methods: We used the example of processing a piece of skeletal muscle in a pathology laboratory to make a video. We developed the video by dividing it into 3 phases: preproduction, production, and postproduction. After writing the learning outcomes, we created a storyboard and script, which were validated by subject matter and audiovisual experts. Photos and videos were captured on a digital camera mounted on a monopod. Video editing software was used to sequence the video clips and photos, insert text and audio narration, and generate closed captions. The finished video was uploaded to YouTube (Google) and then inserted into open-source authoring software to enable an interactive quiz., Results: The final video was 4 minutes and 4 seconds long and took 70 hours to create. The final video included audio narration, closed captioning, bookmarks, and an interactive quiz. We identified that an effective video has six key factors: (1) clear learning outcomes, (2) being engaging, (3) being learner-centric, (4) incorporating principles of multimedia learning, (5) incorporating adult learning theories, and (6) being of high audiovisual quality. To ensure educational quality, we developed a checklist of elements that educators can use to develop a video. One of the barriers to creating procedural videos for a clinician educator who is new to making videos is the significant time commitment to build videography and editing skills. The facilitators for developing an online video include creating a community of practice and repeated skill-building rehearsals using simulations., Conclusions: We outlined the steps in procedural video production and developed a checklist of quality elements. These steps and the checklist can guide a clinician educator in creating a quality video while recognizing the time, technical, and cognitive requirements., (©Komal Srinivasa, Amanda Charlton, Fiona Moir, Felicity Goodyear-Smith. Originally published in JMIR Medical Education (https://mededu.jmir.org), 07.08.2024.)

Introduction: Health disparities between rural and urban areas in Aotearoa New Zealand are exacerbated by rural workforce issues. Traditionally, undergraduate medical programs are urban-based, and reconfiguring the curriculum to meet the needs of rural communities is challenging. The aim of this project is explore how urban-located universities might develop and implement a rural strategy. Evaluation of a rural strategy may lead to the strategy's ongoing improvements designed to increase the rural workforce., Methods: This is a qualitative study involving semi-structured interviews with purposively selected key stakeholders. Enquiry included the systematic identification of processes required to develop a rural strategy, including possible facilitators and challenges to be addressed. Qualitative analysis of de-identified data was conducted using a thematic approach., Results: Fourteen stakeholders were interviewed: four rural GPs, two rural hospital doctors, four administrators involved in placing students, and four senior medical academics with involvement in the regional and rural programs. Five overarching themes were identified: (1) developing rural pathways into medical school, (2) improving and expanding rural exposures, (3) developing rural GP pathways, (4) implementing interprofessional education and (5) having a social mission., Conclusion: These findings align with the literature relating to developing rural strategies for universities. However, this study also suggested that rural health interprofessional programs may have a role. A key finding was that the social mission of a university may not be visible to rural stakeholders. Reorientating an urban-located university to having a rural strategy requires moving past having policy around social accountability to operationalising it.

Community-based primary care, such as general practice (GP) or urgent care, serves as the primary point of access to healthcare for most Australians and New Zealanders. Coronavirus disease 2019 (COVID-19) has created significant and ongoing disruptions to primary care. Traditional research methods have contributed to gaps in understanding the experiences of primary care workers during the pandemic. This paper describes a novel research design and method that intended to capture the evolving impact of the COVID-19 pandemic on primary care workers in Australia and New Zealand. Recurrent, rapid cycle surveys were fielded from May 2020 through December 2021 in Australia, and May 2020 through February 2021 in New Zealand. Rapid survey development, fielding, triangulated analysis and dissemination of results allowed close to real-time communication of relevant issues among general practice workers, researchers and policy-makers. A conceptual model is presented to support longitudinal analysis of primary care worker experiences during the COVID-19 pandemic in Australia and New Zealand, and key learnings from applying this novel method are discussed. This paper will assist future research teams in development and execution of policy-relevant research in times of change and may inform further areas of interest for COVID-19 research in primary care., (© 2024. The Author(s).)

This article outlines the history of abortion law in Aotearoa New Zealand from colonial times to the present. The struggle for law reform has been long and difficult, with marches and rallies, protests and placard-waving, and firebombing of abortion clinics. Aotearoa New Zealand elections have been fought on this issue. Abortion was regulated here under the Crimes Act until 2020. Finally, after 150 years, procuring an abortion in Aotearoa New Zealand is no longer a crime, it is a women's healthcare issue along with others relating to women's reproductive health, including obstetric, contraceptive, sexually transmitted disease and other gynaecological care. The new law promotes autonomy, reproductive health, patient safety and health equity. The abortion struggle serves as an illustration of our changing political and social landscape, with a public move from conservative towards more liberal values. However, the issue continues to divide people, and events in the United States have shown how quickly change can occur, with their Supreme Court overturning Roe v Wade and states now banning abortions. We should not be complacent., Competing Interests: Nil., (© PMA.)

Background: Telehealth involves real-time communication (telephone or video-call) between patients and health providers. The COVID-19 pandemic propelled general practitioners to conduct most consultations remotely, seeing patients face-to-face only when required. Placement opportunities and experience for medical students were reduced. Initially online learning programmes replaced clinical attachments. Subsequently, clinical teachers supervised students to engage in remote consultations, either in clinics or from their homes. This study aimed to explore the experience of New Zealand general practitioners undertaking clinical teaching with medical students when telehealth consulting., Methods: Semi-structured interviews with general practitioners who had taught medical students whilst consulting remotely. General inductive thematic analysis of transcribed interviews., Results: Six female and four male participants aged 40 to over 65 years. Participants often focused on general practicalities of telehealth consultations and effects on the patient-doctor relationship, and needed direction to consider remote consultations with students, which added to the interactions. Four themes were identified: changes needed in teaching delivery format; direct comparison with face-to-face; challenges and advantages to remote teaching, each with subthemes., Discussion: Clinicians needed to determine practical logistics and develop skills for both remote consulting and teaching. New format and structures of consultations needed planning. Differences from face-to-face teaching included scene-setting for the consultation and supervision factors. Telehealth teaching conferred new opportunities for learning but also challenges (e.g. consent, cues, uncertainty). Remote consultations are likely to remain a significant mode for doctor-patient interactions. Preliminary guidelines for teaching and learning using telehealth need to be developed and embedded into medical programmes and then evaluated.

Background: Brown Buttabean Motivation (BBM) is an organization providing support for Pacific people and Indigenous Māori to manage their weight, mainly through community-based exercise sessions and social support. It was started by DL, a man of Samoan and Māori descent, following his personal weight loss journey from a peak weight of 210 kg to less than half that amount. DL is a charismatic leader with a high media profile who is successful in soliciting donations from corporations in money and kindness. Over time, BBM's activities have evolved to include healthy eating, food parcel provision, and other components of healthy living. A co-design team of university researchers and BBM staff are evaluating various components of the program and organization., Objective: The purpose of this study is to build culturally centered system dynamics logic models to serve as the agreed theories of change for BBM and provide a basis for its ongoing effectiveness, sustainability, and continuous quality improvements., Methods: A systems science approach will clarify the purpose of BBM and identify the systemic processes needed to effectively and sustainably achieve the study's purpose. Cognitive mapping interviews with key stakeholders will produce maps of their conceptions of BBM's goals and related cause-and-effect processes. The themes arising from the analysis of these maps will provide the initial indicators of change to inform the questions for 2 series of group model building workshops. In these workshops, 2 groups (BBM staff and BBM members) will build qualitative systems models (casual loop diagrams), identifying feedback loops in the structures and processes of the BBM system that will enhance the program's effectiveness, sustainability, and quality improvement. The Pacific and Māori team members will ensure that workshop content, processes, and outputs are grounded in cultural approaches appropriate for the BBM community, with several Pacific and Māori frameworks informing the methods. These include the Samoan fa'afaletui research framework, which requires different perspectives to be woven together to create new knowledge, and kaupapa Māori-aligned research approaches, which create a culturally safe space to conduct research by, with, and for Māori. The Pacific fonofale and Māori te whare tapa whā holistic frameworks for interpreting people's dimensions of health and well-being will also inform this study., Results: Systems logic models will inform BBM's future developments as a sustainable organization and support its growth and development beyond its high dependence on DL's charismatic leadership., Conclusions: This study will adopt a novel and innovative approach to co-designing culturally centered system dynamics logic models for BBM by using systems science methods embedded within Pacific and Māori worldviews and weaving together a number of frameworks and methodologies. These will form the theories of change to enhance BBM's effectiveness, sustainability, and continuous improvement., Trial Registration: Australian New Zealand Clinical Trial Registry ACTRN 12621-00093-1875; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382320., International Registered Report Identifier (irrid): PRR1-10.2196/44229., (©Faasisila Savila, Truely Harding, Boyd Swinburn, Warwick Bagg, Dave Letele, Fuatino Laban, Felicity Goodyear-Smith. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 16.06.2023.)

Dr Julian Tudor Hart inspired me when I worked as a locum general practitioner in the neighbouring village to Glyncorrwg, southern Wales, in 1979. Our conversations helped shape my subsequent career. But it was only years later I learned that Julian was an icon of general practice and author of the famous 'inverse care law'. Julian was both a truly compassionate dedicated general practitioner in Glyncorrwg, an impoverished Welsh working-class coal-mining village, and an epidemiologist, conducting robust research in partnership with his patients. Patients were co-producers of the research designed to improve their health outcomes. Julian led the way in advocating that first-contact, continuous, comprehensive, and coordinated care for everyone was necessary to achieve equitable health outcomes. He conducted research neither for its own sake nor for his academic advancement. His aim was always to help improve people's lives. He identified that good medical care was least likely to be available for populations most in need. More than that, he demonstrated throughout his exemplary career how it was possible to work with a socioeconomically disadvantaged community to both discover their health needs and also provide equitable personalised health care to all. His legacy lives on.

Competing Interests: DPM is supported as a fellow of the Wingara Mura Leadership Program, University of Sydney and received a grant from The University of Sydney, Charles Perkins Centre Aboriginal and Torres Strait Islander Wingara Mura Leadership Academy Early to Mid-Career Research Seeding Grant; associated manuscript processing charges will be costed to these funds. LM-B received a NHMRC Australia grant to their university for salary and research projects, including Global Alliance for Chronic Diseases (GACD), and was a board member for the Australian Diabetes Society 2014–2021. GSG received consulting fees from the Australian Department of Health and NSW Health for their role on a national advisory panel review about medications for smoking cessation and clinical work in refugee health; had unpaid leadership roles for the Global Alliance for Chronic Disease and Global Implementation Society; and received grants to their institution for research into Indigenous smoking cessation from the Australian Department of Health, NHMRC, GACD and Cancer Australia and Cure Cancer Australia. AGT received grants from NHMRC Australia (grant numbers 1143155, 1171966, and 1182071) and a Medical Research Future Fund (Australian Government; grant number 2015976) while writing the grant; funds were made to their institution. JAA received a NHMRC Australia, GACD grant for the Breathe Easy, Walk Easy, Lungs for Life (BE WELL) project and grant funds used to attend annual GACD scientific meetings. KSL received NHMRC Centre of Research Excellence (application number 1117198) and Ideas grant (application number 1183744). MC received a GACD/Canadian Institute of Health Research (CIHR) grant to their institution. MA received a CIHR grant for a research programme with Indigenous communities (commercial tobacco harm reduction) and is a Pallium Canada board member. FGo-Sm received Global Alliance for Chronic Diseases-Health Research Council funding to their institution in 2017 (reference: 17/705). DM received a postgraduate scholarship from the National Health and Medical Research Council (NHMRC), Australia while preparing this manuscript; was an unpaid member of Australian Diabetes Association's Clinical Advisory Sub-Committee and the Northern Territory Maternal and Neonatal Network. These institutions had no role or influence on the content of the manuscript. All other authors declare no competing interests. We acknowledge all members of the GACD Indigenous Population Working Group for their advice, guidance and support preparing this statement. This statement reflects the perspectives of the contributing authors of the GACD Indigenous Populations Working Group, but it does not necessarily reflect the perspective of GACD and the funding agencies.

Introduction Rheumatic fever is a preventable illness caused by untreated Group A Streptococcus (GAS) infection. Despite reductions in most high-income countries, rheumatic fever rates remain a concern in Aotearoa New Zealand. Pacific and Māori people are inequitably affected, with risk of initial hospitalisation due to rheumatic fever 12- and 24-fold more likely, respectively, compared to non-Māori and non-Pacific people. Aim This scoping review aims to explore the range of interventions and initiatives in New Zealand seeking to prevent GAS and rheumatic fever, with a particular focus on Pacific and Māori. Methods Databases Scopus, Medline, EMBASE and CINAHL, along with grey literature sources, were searched to broadly identify interventions in New Zealand. Data were screened for eligibility and the final articles were charted into a stocktake table. Results Fifty-eight studies were included, reporting 57 interventions. These targeted school-based throat swabbing, awareness and education, housing, secondary prophylaxis, improving primary care guidelines and diagnosis of sore throats and skin infections. Some interventions reported short-term outcomes of improvements in awareness, a reduction in rheumatic fever risk and fewer hospitalisations. Evaluation outcomes were, however, lacking for many initiatives. Pacific and Māori people primarily served only in an advisory or delivery capacity, rather than as partners in co-design or leadership from the beginning. Discussion Although positive outcomes were reported for some interventions identified in this review, rheumatic fever rates have not shown any long-term reduction over time. Co-designing interventions with affected communities could ensure that strategies are better targeted and do not contribute to further stigma.

Introduction Gout in Aotearoa New Zealand (NZ) remains an equity issue. The prevalence in Pacific and Māori people is one of the highest internationally. Although Pacific and Māori experience earlier onset and higher burden of gout, which can severely impact their quality of life, their management of it is often sub-optimal. Aim To conduct a scoping review of the NZ literature for interventions to improve the uptake/management of allopurinol for gout and their evaluation. Methods Databases Medline, Scopus, Embase, and CINAHL Plus and the grey literature were searched systematically to identify all NZ intervention studies aiming to improve allopurinol uptake for gout treatment. Interventions included: if they were delivered in NZ, aimed to improve allopurinol uptake, and were provided in English. A narrative approach was used to extract and synthesise data. Results Eighteen peer-reviewed and grey literature publications met the search criteria. Interventions clustered into three domains: multifaceted or multi-practitioner; gout app; and online booklets or fact sheets. Serum urate levels improved in multi-faceted or multi-practitioner interventions only, whereas the gout app only improved patients' awareness and understanding of gout and medications. Online fact sheets and booklets need more active utilisation from health professionals to improve gout health literacy. Discussion Most gout interventions in NZ use multifaceted or multi-practitioner approaches. Although most interventions successfully controlled serum urate levels and improved equitable access for gout patients to urate-lowering therapy, these interventions did not sustain retention, completion, and engagement for certain population groups, particularly Pacific and Māori, who experience a higher burden of gout.

Background: An integrated primary health care approach, where primary care and public health efforts are coordinated, is a key feature of routine immunisation campaigns., Aim: The aim of the study is to describe the approach used by a diverse group of international primary health care professionals in delivering their coronavirus disease 2019 (COVID-19) vaccination programmes, as well as their perspectives on public health and primary care integration while implementing national COVID-19 vaccination programmes in their own jurisdictions., Setting: This is a protocol for a study, which consists of a cross-sectional online survey disseminated among a convenience sample of international primary health care professional through member-based organisations and professional networks via email and online newsletters., Methods: Survey development followed an iterative validation process with a formative committee developing the survey instrument based on study objectives, existing literature and best practices and a summative committee verifying and validating content., Results: Main outcome measures are vaccination implementation approach (planning, coordination service deliver), level or type of primary care involvement and degree of primary care and public health integration at community level., Conclusion: Integrated health systems can lead to a greater impact in the rollout of the COVID-19 vaccine and can ensure that we are better prepared for crises that threaten human health, not only limited to infectious pandemics but also the rising tide of chronic disease, natural and conflict-driven disasters and climate change.Contribution: This study will provide insight and key learnings for improving vaccination efforts for COVID-19 and possible future pandemics.

Background: Starfield described the importance of system-level components of primary care (first contact, continuous, comprehensive, coordinated), on countries' health systems. It is postulated that, at the individual level, interpersonal interactions and relationship-centred care are central to primary care., Aim: To explore the impact of COVID-19 on disruption to the doctor-patient relationship and subsequent development of new models of care., Design & Setting: A series of 11 cross-sectional surveys of New Zealand (NZ) urban and rural primary care doctors, nurses, and managers, from May 2020 to February 2021, to understand and monitor responses to the pandemic., Method: Using inductive content analysis, cumulated qualitative data from doctors were examined through the lenses of the doctor-patient relationship, its disruption, and resulting changes in models of care., Results: There were 1519 responses to the surveys, representing 482 unique participants. The majority (86%) of responses were from doctors. The following four key themes emerged: moving to transactional consultations; task-shifting with team changes; creating a production line; and diminished communication and coordination across services., Conclusion: The advent of the pandemic led to severe and ongoing strain on practices requiring rapid change to the model of care. Team members took on new roles for triaging, testing, and separating patients with respiratory and non-respiratory symptoms. There was a rapid move to telehealth, with policies developed on where face-to-face consultations were necessary. Practice strain was exacerbated by disruption to coordination with secondary and other referral services. As new models of general practice develop, further disruptions to development of doctor-patient relationships must be avoided. This work extends Starfield's system-level paradigm to the individual level, with the core value of primary care the doctor-patient relationship. Successful sustainable models are likely to be where relationships are treated as of central importance., (Copyright © 2022, The Authors.)

Objective: To learn from primary health care experts' experiences from the COVID-19 pandemic across countries., Methods: We applied qualitative thematic analysis to open-text responses from a multinational rapid response survey of primary health care experts assessing response to the initial wave of the COVID-19 pandemic., Results: Respondents' comments focused on three main areas of primary health care response directly influenced by the pandemic: 1) impact on the primary care workforce, including task-shifting responsibilities outside clinician specialty and changes in scope of work, financial strains on practices, and the daily uncertainties and stress of a constantly evolving situation; 2) impact on patient care delivery, both essential care for COVID-19 cases and the non-essential care that was neglected or postponed; 3) and the shift to using new technologies., Conclusions: Primary health care experiences with the COVID-19 pandemic across the globe were similar in their levels of workforce stress, rapid technologic adaptation, and need to pivot delivery strategies, often at the expense of routine care., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Long COVID is a poorly understood condition, with a wide spectrum of effects on multiple body systems and variable presentation in different individuals. Long COVID is of particular concern among older people (ie, aged 65 years or older), who are at greater risk than younger people of persisting symptoms associated with COVID-19. In addition, COVID-19 might trigger or exacerbate chronic conditions that occur commonly in older people, such as cardiovascular diseases, respiratory diseases, neurodegenerative conditions, and functional decline. In addition, the disruptive effects of COVID-19 for older people should not be underestimated; lockdowns and other restrictions might have reduced the social interactions of older people, and they are also likely to have lost a spouse or loved one during the pandemic, which can contribute to mental and physical decline. COVID-19 vaccination appears to reduce the effects of long COVID, and older people, especially those living in aged care facilities, should remain up-to-date with their COVID-19 vaccinations. Health-care staff should also consider long COVID in the differential diagnosis of relevant symptoms in older people, rather than assume increasing frailty, and should pursue early multidisciplinary assessment and management of persisting symptoms. Addressing physical, psychological, and functional sequelae will mitigate the effect of long COVID and improve the health and quality of life of older people., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Introduction: The community group Brown Buttabean Motivation (BBM) initially began to assist Auckland Pasifika and Māori to manage weight problems, predominantly through community-based exercise sessions and social support. BBM's activities expanded over time to include many other components of healthy living in response to community need. With advent of the COVID-19 pandemic, BBM outreach grew to include a foodbank distributing an increasing amount of donated healthy food to families in need, a community kitchen and influenza and COVID-19 vaccine drives. A strong social media presence has served as the main means of communication with the BBM community as well as use of traditional news media (written, radio, television) to further engage with vulnerable members of the community., Methods and Analysis: The study aims to conduct mixed method process evaluation of BBM's community engagement through in-person, social and news media outreach activities with respect to the health and well-being of Pasifika and Māori over time. The project is informed by theoretical constructs including Pacific Fa'afaletui and Fonofale and Māori Te Whare Tapa Whā Māori research frameworks and principles of Kaupapa Māori. It is further framed using the concept of community-driven diffusion of knowledge and engagement through social networks. Data sources include in-person community engagement databases, social and news media outreach data from archived documents and online resources. Empirical data will undergo longitudinal and time series statistical analyses. Qualitative text thematic analyses will be conducted using the software NVivo, Leximancer and AntConc. Image and video visual data will be randomly sampled from two social media platforms. The social media dataset contains almost 8000 visual artefacts., Ethics and Dissemination: Ethics approval obtained from University of Auckland Human Participants Ethics Committee UAHPEC 23456. Findings will be published in peer-reviewed publications, disseminated through community meetings and conferences and via BBM social network platforms., Trial Registration Number: ACTRN 12621 00093 1875., Competing Interests: Competing interests: DL is the Founder and AB is the Marketing Communications Associate of BBM Motivation, and both are integral members of the research team. WB’s wife is a Pilates instructor at BBM. No other authors have any conflict of interest to declare., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The purpose of this scoping review was to outline the extent of available literature including the prevalence of video quality appraisal tools, characterize how online videos were used, and identify the gaps in the literature with implications for future research., Design: The review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for scoping reviews (PRISMA-ScR). Six databases were searched: (1) MEDLINE (Ovid), (2) EMBASE, (3) Cochrane, (4) ERIC, (5) CINAHL PLUS, and (6) Google Scholar for Medical Subject Headings terms online videos, postgraduate health education, and health professional/s., Results: A total of 6948 articles were identified, of which 78 were included in the review. The articles included were primarily either experimental or observational studies, with most being from North America. Twelve concepts were identified: (1) procedural skills teaching; (2) video assessment; (3) validation of an assessment tool; (4) video feedback; (5) coaching; (6) broadcasting; (7) learner characteristics; (8) video characteristics; (9) video quality; (10) a quality assessment tool; (11) platforms and video library; and (12) health information governance., Conclusions: While there is a diverse and growing body of literature on this area, information is lacking about the quality appraisal of online videos., (Copyright © 2022 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Rheumatic fever is an autoimmune condition that occurs in response to an untreated Group A Streptococcus throat or skin infection. Recurrent episodes of rheumatic fever can cause permanent damage to heart valves, heart failure and even death. Māori and Pacific people in Aotearoa New Zealand experience some of the highest rates globally, with Pacific children 80 times more likely to be hospitalised for rheumatic fever and Māori children 36 times more likely than non-Māori, non-Pacific children. Community members from the Pacific People's Health Advisory Group, research officers from the Pacific Practice-Based Research Network and University of Auckland researchers identified key health priorities within the South Auckland community that needed to be addressed, one of which was rheumatic fever. The study outlined in this protocol aims to co-design, implement, and evaluate a novel intervention to reduce rheumatic fever rates for Pacific communities in South Auckland., Methods: This participatory mixed-methods study utilises the Fa'afaletui method and follows a three-phase approach. Phase 1 comprises a quantitative analysis of the rheumatic fever burden within Auckland and across New Zealand over the last five years, including sub-analyses by ethnicity. Phase 2 will include co-design workshops with Pacific community members, families affected by rheumatic fever, health professionals, and other stakeholders in order to develop a novel intervention to reduce rheumatic fever in South Auckland. Phase 3 comprises the implementation and evaluation of the intervention., Discussion: This study aims to reduce the inequitable rheumatic fever burden faced by Pacific communities in South Auckland via a community-based participatory research approach. The final intervention may guide approaches in other settings or regions that also experience high rates of rheumatic fever. Additionally, Māori have the second-highest incidence rates of rheumatic fever of all ethnic groups, thus community-led approaches 'by Māori for Māori' are also necessary., Trial Registration: The Australian New Zealand Clinical Trial Registry has approved the proposed study: ACTRN12622000565741 and ACTRN12622000572763 ., (© 2022. The Author(s).)

Introduction: Attainment of universal health coverage is feasible via strengthened primary health systems that are comprehensive, accessible, people-centred, continuous and coordinated. Having an adequately trained, motivated and equipped primary healthcare workforce is central to the provision of comprehensive primary healthcare (CPHC). This study aims to understand PHC team integration, composition and organisation in the delivery of CPHC in India, Mexico and Uganda., Methods and Analysis: A parallel, mixed-methods study (integration of quantitative and qualitative results) will be conducted to gain an understanding of PHC teams. Methods include: (1) Policy review on PHC team composition, organisation and expected comprehensiveness of PHC services, (2) PHC facility review using the WHO Service Availability and Readiness Assessment, and (3) PHC key informant interviews. Data will be collected from 20, 10 and 10 PHCs in India, Mexico and Uganda, respectively, and analysed using descriptive methods and thematic analysis approach. Outcomes will include an in-depth understanding of the health policies for PHC as well as understanding PHC team composition, organisation and the delivery of comprehensive PHC., Ethics and Dissemination: Approvals have been sought from the Institutional Ethics Committee of The George Institute for Global Health, India for the Indian sites, School of Medicine Research Ethics Committee at Makerere University for the sites in Uganda and the Research, Ethics and Biosecurity Committees of the Mexican National Institute of Public Health for the sites in Mexico. Results will be shared through presentations with governments, publications in peer-reviewed journals and presentations at conferences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Objectives: The aim was to understand how participants engage with Brown Buttabean Motivation (BBM) a grassroots, Pacific-led holistic health programme and the meaning it has in their lives. The objectives were to explore the impact BBM had on all aspects of their health and well-being, what attracted them, why they stayed, identify possible enablers and barriers to engagement, and understand impact of COVID-19 restrictions., Design: Qualitative study with thematic analysis of semi-structured interviews of BBM participants, followed by theoretical deductive analysis of coded data guided by Pacific Fonofale and Māori Te Whare Tapa Whā health models. In this meeting-house metaphor, floor is family, roof is culture, house-posts represent physical, mental, spiritual and sociodemographic health and well-being, with surroundings of environment, time and context., Setting: Interviews of BBM members conducted in South Auckland, New Zealand, 2020., Participants: 22 interviewees (50% female) aged 24-60 years of mixed Pacific and Māori ethnicities with a mixture of regular members, attendees of the programme for those morbidly obese and trainers., Results: Two researchers independently coded data with adjudication and kappa=0.61 between coders. Participants identified the interactive holistic nature of health and well-being. As well as physical, mental and spiritual benefits, BBM helped many reconnect with both their family and their culture., Conclusions: BBM's primary aim is weight-loss motivation. Many weight loss studies provide programmes to improve physical exercise and nutrition, but seldom address sustainability and other core factors such as mental health. Programmes are often designed by researchers or authorities. BBM is a community-embedded intervention, with no reliance external authorities for its ongoing implementation. It addresses many factors impacting participants' lives and social determinants of health as well as its core business of exercise and diet change. Our results indicate that BBM's holistic approach and responsiveness to perceived community needs may contribute to its sustained success., Competing Interests: Competing interests: DL is the Founder and AB is the Marketing Communications Associate of BBM Motivation, and both are integral members of the research team. WB’s wife is a Pilates instructor at BBM. No other authors have any conflict of interest to declare., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

We report the learnings gleaned from a four-country panel (Australia, South Africa, Egypt and Nigeria) sharing their countries' COVID-19 primary healthcare approaches and implementation of policy at the World Organization of Family Doctor's World virtual conference in November. The countries differ considerably with respect to size, national economies, average age, unemployment rates and proportion of people living rurally. South Africa has fared the worst with respect to waves of COVID-19 cases and deaths. All countries introduced strategies such as border closure, COVID-19 testing, physical distancing and face masks. Australia and Nigeria mobilised primary care, but the response was mostly public health and hospital-based in South Africa and Egypt. All countries rapidly adopted telehealth. All countries emphasised the critical importance of an integrated response between primary care and public health to conduct surveillance, diagnose cases through testing, provide community-based care unless hospitalisation is required and vaccinate the population to reduce infection spread., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Buttabean Motivation (BBM) is a Pacific-led organisation which aims to reduce obesity amongst Pacific and Māori people in New Zealand enabling them to choose a healthy and active life-style for the duration of their lives, their children, their wider family and the community. BBM offers a holistic approach to weight loss, recognising that mental health, family and cultural factors all play essential and critical role in nutrition and physical activity patterns. This study aims to evaluate the effectiveness of BBM for sustained health and wellbeing outcomes among its predominantly Pacific and Māori participants for both general BBM members and those with morbid obesity attending the 'From the Couch' programme., Methods: Quasi-experimental pre-post quantitative cohort study design with measured or self-reported weight at various time intervals for both cohorts. Weight will be analysed with general linear mixed model for repeated measures, and compared with a prediction model generated from the literature using a mixed method meta-analysis. The secondary outcome is change in pre- and post scores of Māori scale of health and well-being, Hua Oranga., Discussion: Multiple studies have shown that many diet and physical activity programmes can create short-term weight loss. The fundamental question is whether BBM members maintain weight loss over time. In New Zealand, Pacific and Māori engagement in health enhancing programmes remains an important strategy for achieving better health and wellbeing outcomes, and quality of life. Internationally, the collectivist cultures of indigenous and migrant and minority populations, living within dominant individualist western ideologies, have much greater burdens of obesity. If BBM members demonstrate sustained weight loss, this culturally informed community-based approach could benefit to other indigenous and migrant populations., Trial Registration: Australian New Zealand Clinical Trial Registry ACTRN12621000931875 (BBM general members) First submitted 10 May 2021, registration completed 15 July 2021. ACTRN12621001676808 7 (From the Couch) First submitted 28 October 2021, registration completed 7 December 2021., (© 2022. The Author(s).)

Background: Pelvic floor muscle training (PFMT) is one of the first-line treatments for stress urinary incontinence among pregnant women. Mobile health (mHealth) technology is potentially effective for delivering PFMT to pregnant women. Persuasive technology in the development of such mobile apps may facilitate behavior change by improving adherence to the exercises. The Capability, Opportunity, and Motivation-Behavior (COM-B) model is potentially useful in selecting the appropriate interventions to be incorporated into the apps., Objective: This review of mHealth apps for PFMT aims to describe the principles of persuasion used for each app and to propose mHealth app design features based on the COM-B model., Methods: A systematic literature search was conducted to answer three main research questions: what are the available mHealth apps for PFMT in the published literature, what persuasive strategies were used in their studies how were they mapped to the COM-B model, and how effective were the selected persuasive strategies for PFMT adherence? We searched PubMed, CINAHL, Web of Science, Scopus, and local Malaysian databases such as MyCite and MyMedR for articles reporting mHealth apps used for the delivery of PFMT. We included original articles reporting experimental and cross-sectional studies, including pilot or feasibility trials. Systematic and narrative reviews were excluded. Narrative and thematic syntheses were conducted on the eligible articles based on the research questions. The Cochrane risk of bias tool and the Risk of Bias Assessment Tool for Non-randomized Studies were used to assess study bias., Results: Of the 169 records from the initial search, 10 (5.9%) articles meeting the selection criteria were included in this review. There were 8 mHealth apps designed for the delivery of PFMT. The Tät, which used 3 categories of persuasive system design, improved PFMT adherence and was cost-effective. Only 1 app, the iBall app, used all categories of persuasive system design, by including social support such as "competition" in its design. The Diário Saúde app was the only app developed using operant conditioning. All apps incorporated Tailoring and Expertise as part of their PSD strategies. Only 3 apps, the Diário Saúde, Tät, and Pen Yi Kang demonstrated improved PFMT adherence., Conclusions: Persuasive technology used in mobile apps may target desired behavior change more effectively. The persuasive system design can be mapped to the COM-B model to explain its effectiveness on behaviour change outcomes., (©Aida Jaffar, Chai-Eng Tan, Sherina Mohd-Sidik, Novia Admodisastro, Felicity Goodyear-Smith. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 22.03.2022.)

Introduction: In countries such as New Zealand, where there has been little community spread of COVID-19, psychological distress has been experienced by the population and by health workers. COVID-19 has caused changes in the model of care that is delivered in New Zealand general practice. It is unknown, however, whether the changes wrought by COVID-19 have resulted in different levels of strain between rural and urban general practices. This study aims to explore these differences from the impact of COVID-19., Methods: This study is part of a four-country collaboration (Australia, New Zealand, Canada and the USA) involving repeated cross-sectional surveys of primary care practices in each respective country. Surveys were undertaken at regular intervals throughout 2020 of urban and rural general practices throughout New Zealand. Five core questions were asked at each survey, relating to experiences of strain, capacity for testing, stressors experienced, types of consultations being carried out and numbers of patients seen. Simple descriptive statistics were used to analyse the data., Results: A total of 1516 responses were received with 20% from rural practices. A moderate degree of strain was experienced by general practices, although rural practices appeared to experience less strain compared to urban ones. Rural practices had fewer staff absent from work, were less likely to use alternative forms of consultations such as video consultations and telephone consultations, and had possibly lower reductions in patient volumes. These variations might be related to personal characteristics of rural as compared to urban practices or different models of care., Conclusion: New Zealand rural general practice appeared to have a different response to the COVID-19 pandemic compared to urban general practice, illustrating the significant strengths and resilience of rural practices. While different experiences from COVID-19 might reflect differences in the demographics of the rural and urban general practice workforce, another proposition is that this difference indicates a rural model of care that is more adaptive compared to the urban one. This is consistent with the literature that rural general practice has the capacity to manage conditions in a different way to urban. While other comparable countries have demonstrated a unique rural model of care, less is known about this in New Zealand, adding weight to an argument to further define New Zealand rural general practice.

Issue Addressed: Diabetes mellitus is an increasing global health problem, particularly in Vanuatu, where it poses a major health burden. There is paucity of information on how patients in Vanuatu perceive diabetes, diabetic retinopathy, access to services and management, health promotion and intervention services to alleviate the issues. This study aimed to explore the perceptions of diabetic patients in Vanuatu on these issues, to help inform the design of health promotion materials and community activities to empower people to self-manage and shape diabetic services that are integrated and people-centred., Methods: Qualitative Talanga and Kakala Pacific research methodologies were applied. Participants were diabetic patients from both urban locations and rural villages in Vanuatu. Data were collected from four (two male, two female) focus group interviews and thematically analysed., Results: There were 26 participants. System failures became apparent, including the inability of the health care services to meet the complex needs of patients with diabetes. The protective factors to reduce the risk and increasing incidence of diabetes and diabetic retinopathy included comprehensive village-based health promotion and community development programmes at the primary prevention level., Conclusion: This study described patients' experiences of their diabetic care and identified key barriers and facilitators of service delivery pathways. SO WHAT?: Vanuatu needs to expand nationwide health promotion and education programmes on nutrition and exercise, food insecurity and access through trade agreements and provide well-trained nursing and medical specialists for early diagnosis and adequate management of diabetes that all people can access and afford., (© 2021 Australian Health Promotion Association.)

Background: Gout is a painful chronic disease which disrupts work and family life and can lead to chronic joint damage. Pacific people in Aotearoa/New Zealand experience significant inequities, with over three times the gout prevalence of the non-Pacific non-Māori populations. Pacific people receive less regular urate-lowering drugs to prevent gout flare-ups, and have nine times the hospitalisation from gout compared with non-Pacific non-Māori people. Rates for Indigenous Māori lie between Pacific and non-Pacific non-Māori. A long-established Collective comprising community members from the Pacific People's Health Advisory Group, clinical staff from the Pacific Practice-Based Research Network, and University of Auckland researchers have identified that improving Pacific urate-lowering therapy use as the research question of prime importance for improved health outcomes of Pacific people in South Auckland. Building on the existing knowledge, this study aims to develop, implement and evaluate a novel innovative intervention to improve the uptake of urate-lowering therapy by Pacific patients with gout., Methods: Three-phase mixed methods co-design study using the Fa'afaletui research framework following the STROBE statement. Phase1 is observational times series of prevalence of patients with gout, proportion with urate blood-level monitoring and use of urate-lowering medication over past 5 years. In Phase 2 the Collective will workshop new interventions to address previous uptake barriers, using culturally-appropriate Talanga communications with results synthesised in line with Kakala principles. The designed intervention will be implemented and process and outcome evaluations conducted. Finally, an implementation framework will be produced to facilitate further roll-out., Discussion: The study aims to enhance health and reduce inequities for Pacific people, contribute to creation of Pacific health knowledge and translation of research findings into Pacific health gains. Potential longer-term impact is a gout-management pathway for use throughout Aotearoa/New Zealand. Māori have similar issues with high gout prevalence and low urate-lowering therapy use hence the intervention is likely to translate to Māori healthcare. The project will contribute to Pacific research capacity and capability-building as well as general upskilling of community and practice members involved in the co-design processes., Trial Registration: The Australian New Zealand Clinical Trial Registry is in process, request number 38206, 1-09-2021., (© 2021. The Author(s).)

Background: Adolescents often present at primary care clinics with nonspecific physical symptoms when, in fact, they have at least 1 mental health or risk behavior (psychosocial) issue with which they would like help but do not disclose to their care provider. Despite global recommendations, over 50% of youths are not screened for mental health and risk behavior issues in primary care., Objective: This review aimed to examine the implementation, acceptability, feasibility, benefits, and barriers of e-screening tools for mental health and risk behaviors among youth in primary care settings., Methods: Electronic databases-MEDLINE, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews-were searched for studies on the routine screening of youth in primary care settings. Screening tools needed to be electronic and screen for at least 1 mental health or risk behavior issue. A total of 11 studies that were reported in 12 articles, of which all were from high-income countries, were reviewed., Results: e-Screening was largely proven to be feasible and acceptable to youth and their primary care providers. Preconsultation e-screening facilitated discussions about sensitive issues and increased disclosure by youth. However, barriers such as the lack of time, training, and discomfort in raising sensitive issues with youth continued to be reported., Conclusions: To implement e-screening, clinicians need to change their behaviors, and e-screening processes must become normalized into their workflows. Co-designing and tailoring screening implementation frameworks to meet the needs of specific contexts may be required to ensure that clinicians overcome initial resistances and perceived barriers and adopt the required processes in their work., (©Rhiannon Martel, Matthew Shepherd, Felicity Goodyear-Smith. Originally published in JMIR Mental Health (https://mental.jmir.org), 19.11.2021.)

Background: Authorities need to recognize that, while rare, gonorrhea can be transmitted nonsexually, and should not be presumed definitive evidence of abuse. We report the unusual case of a girl diagnosed with Neisseria gonorrhoeae after bathing in a heavily frequented hot pool at the edge of the crater lake Specchio di Venere ("Mirror of Venus") on Pantelleria Island, Italy., Case Presentation: Two days after bathing in the pool, this 11-year-old Austrian girl developed vulvovaginitis that partially settled with antifungal cream. Subsequent swabs cultured positive for Neisseria gonorrhoeae. Family members tested negative. The child adamantly denied any sexual contact, and no opportunities for sexual exposure could be identified. It was therefore concluded that she must have acquired the infection from pool water contaminated by gonococcus after a 2-day incubation period. The infection was successfully treated with ceftriaxone and azithromycin with no adverse effects., Conclusions: The pools are shallow, close to body temperature, isotonic, slightly acidic from CO 2 bubbles, and contain organic particles, all potentially supporting survival of gonococcus. There are historical case reports in the literature of gonococcal epidemics in children's hospitals being traced to common baths. It is imperative that all cases of gonococcal infection in children are fully investigated, including examining all other relevant family members, to determine whether sexual assault has occurred. This is not a diagnosis to be missed. However, both sexual and nonsexual transmission are possible. A presumption that a gonococcal infection is diagnostic of sexual abuse can be dire, with children wrongfully removed from their parents' care, and their caregivers facing false charges of sexual crimes. Our case serves to illustrate that the very uncommon diagnosis of gonorrhea in a child may be the result of nonsexual transmission of the infection, and that contaminated hot pools are a very rare source of infection that should be considered., (© 2021. The Author(s).)

Diabetes mellitus is an increasing global health problem affecting millions of people worldwide, especially true in the Republic of Kiribati, with >20% of adults suffering from type 2 diabetes, and the prevalence is rising. Information on I-Kiribati patients' understanding of diabetes and perception of access to relevant services is sparse. This study explores patient perspectives on their condition and its management using Talanga and Kakala Pacific research methodologies. Data were collected from Kiribati patients in four focus group interviews. Key themes to emerge were knowledge about diabetes, understanding and accessing the health care system, making lifestyle changes, and suggestions for improvement. Health system failures to meet the complex health care needs of these patients and health care services gaps are apparent. Improvements suggested include a comprehensive village-based health promotion and community development program focusing on youth and schools from early childhood and onward, increase in the skilled workforce, and an integrated approach to service delivery.

While the COVID-19 pandemic now affects the entire world, countries have had diverse responses. Some responded faster than others, with considerable variations in strategy. After securing border control, primary health care approaches (public health and primary care) attempt to mitigate spread through public education to reduce person-to-person contact (hygiene and physical distancing measures, lockdown procedures), triaging of cases by severity, COVID-19 testing, and contact-tracing. An international survey of primary care experts' perspectives about their country's national responseswas conducted April to early May 2020. This mixed method paper reports on whether they perceived that their country's decision-making and pandemic response was primarily driven by medical facts, economic models, or political ideals; initially intended to develop herd immunity or flatten the curve, and the level of decision-making authority (federal, state, regional). Correlations with country-level death rates and implications of political forces and processes in shaping a country's pandemic response are presented and discussed, informed by our data and by the literature. The intersection of political decision-making, public health/primary care policies and economic strategies is analysed to explore implications of COVID-19's impact on countries with different levels of social and economic development.

We sought to gain insights into the impacts of COVID-19 and associated control measures on health and health care of patients from low- and middle-income countries with cardiovascular disease, diabetes, and mental health conditions, using an online survey during the COVID-19 pandemic. The most common concern for the 1487 patients who took part was contracting COVID-19 when they accessed health care. Of those infected with COVID-19, half said that their health had been worse since being infected. Collectively, most people reported an increase in feelings of stress and loneliness. The COVID-19 pandemic has led to a range of health care impacts on patients with noncommunicable diseases, including constraints on access to care and health effects, particularly mental well-being., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: K.S., A.M., and P-.H.H. are employees of Viatris., (© The Author(s) 2021.)

Aim: Quick COVID-19 Surveys are an international collaboration designed to rapidly analyse and disseminate a primary care perspective on the pandemic and associated health response. In this paper we present results from surveys relating to opening the New Zealand border., Method: Three surveys were distributed to primary care practices between May and December 2020. A range of primary care member organisations distributed the survey augmented by snowballing. Quantitative data were analysed using descriptive statistics and qualitative data through an inductive process and grouped into themes., Results: Respondents became increasingly supportive of opening a trans-Tasman border but not internationally. Two broad themes were evident: (1) making sure that the border is not an Achilles heel and (2) effective strategies to reduce local transmission. These themes highlight primary care's concerns around management of the border and the management of local spread respectively., Conclusion: The results highlight concerns around border control from a primary care perspective. The border control issues raised by primary care have proven to be prophetic at times and reflect the role that primary care has as observers of society. The survey mechanism provides a template for rapidly eliciting a primary care voice for future health issues., Competing Interests: Nil.

Background: The global COVID-19 pandemic has disrupted healthcare worldwide. In low- and middle-income countries (LMICs), where people may have limited access to affordable quality care, the COVID-19 pandemic has the potential to have a particularly adverse impact on the health and healthcare of individuals with noncommunicable diseases (NCDs). A World Health Organization survey found that disruption of delivery of healthcare for NCDs was more significant in LMICs than in high-income countries. However, the study did not elicit insights into the day-to-day impacts of COVID-19 on healthcare by front-line healthcare workers (FLHCWs)., Aim: To gain insights directly from FLHCWs working in countries with a high NCD burden, and thereby identify opportunities to improve the provision of healthcare during the current pandemic and in future healthcare emergencies., Methods: We recruited selected frontline healthcare workers (general practitioners, pharmacists, and other medical specialists) from nine countries to complete an online survey (n = 1347). Survey questions focused on the impact of COVID-19 pandemic on clinical practice and NCDs; barriers to clinical care during the pandemic; and innovative responses to the many challenges presented by the pandemic., Findings: The majority of FLHCWs responding to our survey reported that their care of patients had been impacted both adversely and positively by the public health measures imposed. Most FLHCs (95%) reported a deterioration in the mental health of their patients., Conclusions: Continuity of care for NCDs as part of pandemic preparedness is needed so that chronic conditions are not exacerbated by public health measures and the direct impacts of the pandemic.

Primary health care (PHC) includes both primary care (PC) and essential public health (PH) functions. While much is written about the need to coordinate these two aspects, successful integration remains elusive in many countries. Furthermore, the current global pandemic has highlighted many gaps in a well-integrated PHC approach. Four key actions have been recognized as important for effective integration.A survey of PC stakeholders (clinicians, researchers, and policy-makers) from 111 countries revealed many of the challenges encountered when facing the pandemic without a coordinated effort between PC and PH functions. Participants' responses to open-ended questions underscored how each of the key actions could have been strengthened in their country and are potential factors to why a strong PC system may not have contributed to reduced mortality.By integrating PC and PH greater capacity to respond to emergencies may be possible if the synergies gained by harmonizing the two are realized.

Primary care (PC) is an essential building block for any high quality healthcare system, and has a particularly positive impact on vulnerable patients. It contributes to the overall performance of health systems, and countries that reorient their health system towards PC are better prepared to achieve universal health coverage. Monitoring the actual performance of PC in health systems is essential health policy to support PC. However, current indicators are often too narrowly defined to account for quality of care in the complex populations with which PC deals. This article reviews a number of conceptual frameworks developed to capture PC values in robust measures and indicators that can inform policy and practice performance. Each have benefits and limitations. Further work is needed to develop meaningful primary health care (PHC) and PC measures to inform strategic action by policymakers and governments for improved overall performance of health systems., (Copyright © 2021, The Authors.)

INTRODUCTION New Zealand veterans may have complex mental and physical complaints related to multiple exposures to war environments. They are entitled to, but often do not, access a range of physical, mental health and social services funded through Veterans' Affairs New Zealand. eCHAT (electronic Case-finding and Help Assessment Tool) is a self-completed electronic holistic screen for substance misuse, problem gambling, anger control, physical inactivity, depression, anxiety, exposure to abuse; and assesses whether help is wanted for identified issues. AIM A proof-of-concept study was conducted to develop a modified version of eCHAT (VeCHAT) with remote functionality for clinical assessment of mental health and lifestyle issues of contemporary veterans, and assesses acceptability by veterans and Veterans' Affairs staff, and feasibility of implementation. METHODS We used a co-design approach to develop VeCHAT. Veterans' Affairs and service organisations invited veterans to remotely complete VeCHAT and a subsequent short online acceptability survey. Veterans' Affairs medical and case manager staff underwent semi-structured interviews on feasibility and acceptability of VeCHAT use. RESULTS Thirty-four veterans completed VeCHAT. The tool proved acceptable to veterans and Veterans' Affairs staff. Key emergent themes related to tool functionality, design, ways and barriers to use, and suggested improvements. Veterans' Affairs staff considered VeCHAT use to be feasible with much potential. DISCUSSION Capacity of Veterans' Affairs to respond if their engagement with veterans increases and employment of VeCHAT is scaled up, is unknown. Work is needed to assess how introducing VeCHAT as a standard procedure might influence Veterans' Affairs case management processes.

Introduction: Pelvic floor muscle training (PFMT) strongly recommended to incontinent pregnant women. The Kegel Exercise Pregnancy Training-app trial is a multicentre cluster-randomised study aims to assess the effectiveness and its cost-effectiveness of the mobile app guidance in PFMT among incontinent pregnant women., Methods and Analysis: 370 pregnant women (aged 18 years old and above) will be recruited with International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form. Ten clusters (primary care clinics) will be randomly assigned to either PFMT or usual care in a 1:1 ratio by an independent researcher (sealed envelope). The primary outcome will be urinary incontinence, and the secondary outcomes (quality of life; PFMT adherence, psychological status and mobile apps' usability) will be assessed at four measurement time points (t0: baseline) and postintervention (t1: 4 weeks, t2: 8 weeks and t3: 8 weeks postnatal). T-test analysis will determine any significant differences at the baseline between the control and intervention groups. The mixed-model analysis will determine the effectiveness of the intervention at the population-average level for both the primary and secondary outcomes. For the cost-effectiveness analysis, expenditures during the study and 6 months after the intervention will be compared between the groups using the multiway sensitivity analysis. The recruitment planned will be in December 2020, and the planned end of the study will be in August 2021., Ethics and Dissemination: This study protocol was approved by the Ethics Committee for Research Involving Human Subjects, Universiti Putra Malaysia (JKEUPM-2019-368) and Medical Research and Ethics Committee (MREC), Ministry of Health Malaysia, NMRR-19-412-47116 (IIR) with the ANZCTR registration. This study will obtain informed written consent from all the study participants. The results which conform with the Consolidated Standards of Reporting Trials and the Recommendations for Interventional Trials will be published for dissemination in peer-reviewed journals and conference proceedings., Trial Registration Number: ACTRN12619000379112., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)